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MANAGEMENT UPDATE

Contemporary Management
of Fibroids in Pregnancy
Hee Joong Lee, MD, PhD,1 Errol R. Norwitz, MD, PhD,2 Julia Shaw, MD, MBA2
1
Department of Obstetrics & Gynecology, The Catholic University of Korea, Seoul, Korea; 2Department of
Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT

Uterine fibroids are a very common finding in women of reproductive age. The
majority of fibroids do not change their size during pregnancy, but one-third
may grow in the first trimester. Although the data are conflicting and most
women with fibroids have uneventful pregnancies, the weight of evidence in
the literature suggests that uterine fibroids are associated with an increased
rate of spontaneous miscarriage, preterm labor, placenta abruption, malpre-
sentation, labor dystocia, cesarean delivery, and postpartum hemorrhage.
[Rev Obstet Gynecol. 2010;3(1):20-27 doi: 10.3909/riog0101]

© 2010 MedReviews®, LLC

Key words: Fibroids • Miscarriage • Preterm labor • Placenta abruption • Fetal anomalies •
Myomectomy • Uterine artery embolization

F
ibroids (leiomyomas) are benign smooth muscle cell tumors of the uterus.
Although they are extremely common, with an overall incidence of 40% to
60% by age 35 and 70% to 80% by age 50, the precise etiology of uterine fi-
broids remains unclear.1 The diagnosis of fibroids in pregnancy is neither simple
nor straightforward. Only 42% of large fibroids ( 5 cm) and 12.5% of smaller
fibroids (3-5 cm) can be diagnosed on physical examination.2 The ability of ultra-
sound to detect fibroids in pregnancy is even more limited (1.4%-2.7%) primarily
due to the difficulty of differentiating fibroids from physiologic thickening of the
myometrium.3-6 The prevalence of uterine fibroids during pregnancy is therefore
likely underestimated. Reflecting the growing trend of delayed childbearing, the
incidence of fibroids in older women undergoing treatment for infertility is re-
portedly 12% to 25%.7 Despite their growing prevalence, the relationship between
uterine fibroids and adverse pregnancy outcome is not clearly understood.

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Prospective studies using ultra-
sound to follow the size of uterine fi-
broids throughout pregnancy have
shown that the majority of fibroids
(60%-78%) do not demonstrate any
significant change in volume during
pregnancy.8,9 Of the 22% to 32% of
fibroids that did increase in volume,
the growth was limited almost exclu-
sively to the first trimester, especially
the first 10 weeks of gestation, with
very little if any growth in the second
and third trimesters. The mean in-
crease in volume in this cohort was
only 12%  6%, and the maximum
growth was only 25% of the initial
volume.8 Some studies have shown
that small fibroids are just as likely to
grow as large fibroids,8 whereas other
studies have suggested that small and
large fibroids ( 6 cm) have different
growth patterns in the second
trimester (small fibroids grow whereas
large fibroids remain unchanged or
decrease in size), but all decrease in
size in the third trimester.9,10 The ma-
jority of fibroids show no change dur-
ing the puerperium, although 7.8%
will decrease in volume by up to
10%.8,9
Most fibroids are asymptomatic.
However, severe localized abdominal
pain can occur if a fibroid undergoes
so-called “red degeneration,” torsion
(seen most commonly with a peduncu-
lated subserosal fibroid), or impaction
(Figure 1). Pain is the most common
complication of fibroids in pregnancy,
and is seen most often in women with
large fibroids ( 5 cm) during the
second and third trimesters of preg-
nancy.3,11 In a study of 113 pregnant
women, 9% of fibroids showed a het-
erogeneous echogenic pattern or cys-
tic changes on ultrasound indicating
the development of red degeneration.
Of these women, 70% (7 of 10) had
severe abdominal pain compared with
11.7% (12 of 103) of women with fi-
broids that showed no echogenic
changes on ultrasound.10 Three main
Management of Fibroids in Pregnancy
theories have been proposed to ex- mechanism by which uterine fibroids
plain the severe pain associated with induce obstetric complications is not
red degeneration. First, that rapid fi- clear.4
broid growth results in the tissue out-
growing its blood supply leading to Early Pregnancy
tissue anoxia, necrosis, and infarc- Miscarriage. Spontaneous miscar-
tion.11,12 Second, that the growing riage rates are greatly increased in
uterus results in a change in the ar- pregnant women with fibroids com-
chitecture (kinking) of the blood sup- pared with control subjects without
ply to the fibroid leading to ischemia fibroids (14% vs 7.6%, respectively).14
and necrosis even in the absence of The weight of evidence in the litera-
fibroid growth.13 Third, that the pain ture suggests that the size of the
results from the release of fibroid does not affect the rate of
prostaglandins from cellular damage miscarriage, but multiple fibroids
within the fibroid. This is supported may increase the miscarriage rate
Early miscarriage is more common in women with fibroids located in the
uterine corpus (body) than in the lower uterine segment and in women with
intramural or submucosal fibroids.
by the observation that ibuprofen and compared with the presence of a sin-
other prostaglandin synthetase in- gle fibroid only (23.6% vs 8.0%).14
hibitors effectively and rapidly con- The location of the fibroid may also
trol fibroid pain.11 be important. Early miscarriage is
more common in women with fi-
Effect of Fibroids on Pregnancy broids located in the uterine corpus
Outcome (body) than in the lower uterine seg-
Approximately 10% to 30% of women ment10 and in women with intramural
with uterine fibroids develop compli- or submucosal fibroids.7,15-17 The
cations during pregnancy.11 However, mechanism by which fibroids cause
these adverse pregnancy outcomes spontaneous abortion is unclear.
have been reported in incomplete set- Increased uterine irritability and con-
tings with selection bias, small and tractility, the compressive effect of fi-
The location of the fibroid determines the risk for bleeding. Bleeding in early
pregnancy is significantly more common if the placenta implants close to the
fibroid compared with pregnancies in which there is no contact between the
placenta and fibroid (60% vs 9%, respectively).
differing populations, varying inclu- broids, and compromise to the blood
sion criteria, low occurrence of ad- supply of the developing placenta and
verse outcomes, and inadequate con- fetus have all been implicated.18
founding variables. As a result, these
studies have reported inconsistent re- Bleeding in early pregnancy. The lo-
lationships between fibroids and ad- cation of the fibroid determines the
verse obstetric outcomes. Although risk for bleeding. Bleeding in early
decreased uterine distensibility or me- pregnancy is significantly more com-
chanical obstruction may explain mon if the placenta implants close to
some adverse outcomes, the precise the fibroid compared with pregnancies
VOL. 3 NO. 1 2010 REVIEWS IN OBSTETRICS & GYNECOLOGY 21
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Management of Fibroids in Pregnancy continued

in which there is no contact between
the placenta and fibroid (60% vs 9%,
respectively).2,19
Late Pregnancy
Preterm labor and preterm prema-
ture rupture of membranes. Preg-
nant women with fibroids are sig-
nificantly more likely to develop
preterm labor and to deliver preterm
than women without fibroids (16.1%
vs 8.7% and 16% vs 10.8%, respec-
tively; Table 1).7 Multiple fibroids
and fibroids contacting the placenta
appear to be independent risk fac-
tors for preterm labor.10,19 In con-
trast, fibroids do not appear to be a
risk factor for preterm premature
rupture of membranes (PPROM).
Indeed, a recent systematic review
suggests that fibroids are associated
with a decreased risk of PPROM
(Table 1).7
Placental abruption. Although re-
ports are conflicting, pooled cumula-
tive data suggest that the risk of pla-
cental abruption is increased 3-fold
in women with fibroids (Table 1).7
Submucosal fibroids, retroplacental
fibroids, and fibroid volumes  200
cm3 are independent risk factors for
placental abruption.20 One retrospec-
tive study reported placental abrup-
tion in 57% of women with retropla-
cental fibroids in contrast with 2.5%
of women with fibroids located in
alternate sites.3 One possible mecha-
nism of placental abruption may be
diminished blood flow to the fibroid
and the adjacent tissues which results
in partial ischemia and decidual
necrosis in the placental tissues over-
laying the leiomyoma.3
Placenta previa. The relationship be-
tween fibroids and placenta previa
has been examined in only 2 studies,
both of which suggest that the pres-
ence of fibroids is associated with a
2-fold increased risk of placenta
previa even after adjusting for prior
surgeries such as cesarean section or
myomectomy (Table 1).4,7,21
Fetal growth restriction and fetal
anomalies. Fetal growth does not ap-
pear to be affected by the presence of
uterine fibroids. Although cumulative
data and a population-based study
suggested that women with fibroids
are at slightly increased risk of deliv-
ering a growth-restricted infant, these
results were not adjusted for maternal
age or gestational age (Table 1).7,22
Rarely, large fibroids can compress
and distort the intrauterine cavity
leading to fetal deformities. A number
of fetal anomalies have been reported
in women with large submucosal

Table 1
Cumulative Risk of Adverse Obstetric Outcomes in Pregnant Women With Fibroids

Unadjusted
Fibroids No Fibroids P Value OR (95% CI)
Cesarean delivery 48.8% (2098/4322) 13.3% (22,989/173,052)  .001 3.7 (3.5-3.9)
Malpresentation 13.0% (466/3585) 4.5% (5864/130,932)  .001 2.9 (2.6-3.2)
Labor dystocia 7.5% (260/3471) 3.1% (4703/148,778)  .001 2.4 (2.1-2.7)
Postpartum hemorrhage 2.5% (87/3535) 1.4% (2130/153,631)  .001 1.8 (1.4-2.2)
Peripartum hysterectomy 3.3% (18/554) 0.2% (27/18,000)  .001 13.4 (9.3-19.3)
Retained placenta 1.4% (15/1069) 0.6% (839/134,685) .001 2.3 (1.3-3.7)
Chorio or endometriosis 8.7% (78/893) 8.2% (2149/26,090) .63 1.06 (0.8-1.3)
IUGR 11.2% (112/961) 8.6% (3575/41,630)  .001 1.4 (1.1-1.7)
Preterm labor 16.1% (116/721) 8.7% (1577/18,187)  .001 1.9 (1.5-2.3)
Preterm delivery 16.0% (183/1145) 10.8% (3433/31,770)  .001 1.5 (1.3-1.7)
Placenta previa 1.4% (50/3608) 0.6% (924/154,334)  .001 2.3 (1.7-3.1)
First-trimester bleeding 4.7% (120/2550) 7.6% (1193/15,732)  .001 0.6 (0.5-0.7)
Abruption 3.0% (115/4159) 0.9% (517/60,474)  .001 3.2 (2.6-4.0)
PPROM 9.9% (123/1247) 13.0% (7319/56,418) .003 0.8 (0.6-0.9)
PPROM or PROM 6.2% (217/3512) 12.2% (7425/60.661)  .001 0.5 (0.4-0.6)
OR, odds ratio; CI, confidence interval; IUGR, intrauterine growth restriction; PPROM, preterm premature rupture of membranes; PROM, premature
rupture of membranes.
Reprinted from American Journal of Obstetrics & Gynecology, Vol. 198, PC Klatsky et al, “Fibroids and reproductive outcomes: a systematic literature
review from conception to delivery," pp. 357-366, Copyright 2008, with permission from Elsevier.7

22 VOL. 3 NO. 1 2010 REVIEWS IN OBSTETRICS & GYNECOLOGY

6. RIOG0101_04-15.qxd 4/15/10 5:16 PM Page 23
fibroids, including dolichocephaly
(lateral compression of the fetal skull),
torticollis (abnormal twisting of the
neck), and limb reduction defects.23-25
Labor and Delivery
Malpresentation, labor dystocia, and
cesarean delivery. The risk of fetal
malpresentation increases in women
with fibroids compared with control
subjects (13% vs 4.5%, respectively;
Table 1).7,22 Large fibroids, multiple
fibroids, and fibroids in the lower
uterine segment have all been re-
ported as independent risk factors for
malpresentation.4,10,21,26
Numerous studies have shown that
uterine fibroids are a risk factor for
cesarean delivery.3,7,10,21,22,27-29 In a
systematic review, women with fi-
broids were at a 3.7-fold increased
risk of cesarean delivery (48.8% vs
13.3%, respectively).7 This is due in
part to an increase in labor dystocia,
which is increased 2-fold in pregnant
women with fibroids (Table 1).7,22
Malpresentation, large fibroids, multi-
ple fibroids, submucosal fibroids, and
fibroids in the lower uterine segment
are considered predisposing factors
for cesarean delivery.5,10,21,27-29 Despite
the increased risk of cesarean, the
presence of uterine fibroids—even
large fibroids ( 5 cm)—should not be
regarded as a contraindication to a
trial of labor.4,21,22
Postpartum hemorrhage. Reports on
the association between fibroids and
postpartum hemorrhage are conflict-
ing.2,10,27,30-32 Pooled cumulative data
suggest that postpartum hemorrhage
is significantly more likely in women
with fibroids compared with control
subjects (2.5% vs 1.4%, respectively;
Table 1).7 Fibroids may distort the
uterine architecture and interfere with
myometrial contractions leading to
uterine atony and postpartum he-
morrhage.33 This same mechanism
may also explain why women with
Management of Fibroids in Pregnancy
fibroids are at increased risk of puer-
peral hysterectomy.3,7,20
Retained placenta. One study re-
ported that retained placenta was
more common in women with fibroids,
but only if the fibroid was located in
the lower uterine segment.10 However,
pooled cumulative data suggest that
retained placenta is more common in
all women with fibroids compared
with control subjects, regardless of
the location of the fibroid (1.4% vs
0.6%, respectively; Table 1).7
Uterine rupture after myomectomy.
Uterine rupture after abdominal my-
omectomy is extremely rare.34-36 In a
retrospective study of 120 women de-
livering at term following abdominal
myomectomy in which the uterine
cavity was not entered, there were no
cases of uterine rupture reported.36
Whether the same is true also of
laparoscopic myomectomy is not
known, because there are numerous
case reports and case series describing
intrapartum uterine rupture after la-
paroscopic myomectomy.37-45 Recent
data suggest that such uterine rup-
tures occur prior to the onset of labor
at the site of the prior laparoscopic
myomectomy.37-39,44 Fortunately, the
absolute risk of uterine rupture fol-
lowing laparoscopic myomectomy
remains low at 0.5% to 1%.41
Effect of Uterine Fibroids
on Pregnancy Management
Pain Management
Fibroid pain during pregnancy is
usually managed conservatively by
bed rest, hydration, and analgesics.
Fibroid pain during pregnancy is usually managed conservatively by bed
rest, hydration, and analgesics.
Prostaglandin synthase inhibitors
(eg, nonsteroidal anti-inflammatory
drugs) should be used with caution,
VOL. 3 NO. 1 2010
especially prolonged use ( 48
hours) in the third trimester where it
has been associated with both fetal
and neonatal adverse effects, includ-
ing premature closure of the fetal
ductus arteriosus, pulmonary hyper-
tension, necrotizing enterocolitis,
intracranial hemorrhage, or oligohy-
dramnios.46 Rarely, severe pain may
necessitate additional pain medica-
tion (narcotic analgesia), epidural
analgesia, or surgical management
(myomectomy).47,48
Myomectomy. Prior to pregnancy,
myomectomy can be considered in
women with unexplained infertility
or recurrent pregnancy loss,49,50
although whether such surgical inter-
ventions actually improve fertility
rates and perinatal outcome remains
unclear.
It is rare for fibroids to be treated
surgically in the first half of pregnancy.
If necessary, however, several studies
have reported that antepartum my-
omectomy can be safely performed in
the first and second trimester of preg-
nancy.12,20,48,51-55 Acceptable indications
include intractable pain from a degen-
erating fibroid especially if it is sub-
serosal or pedunculated, a large or
rapidly growing fibroid, or any large
fibroid ( 5 cm) located in the lower
uterine segment. Obstetric and neona-
tal outcomes in women undergoing
myomectomy in pregnancy are compa-
rable with that in conservatively man-
aged women,20,53 although women who
had a myomectomy during pregnancy
were far more likely to be delivered by
cesarean due to concerns about uterine
rupture (Table 2).12,20,51-55
Although not supported by all stud-
ies,56,57 most authorities agree that
every effort should be made to avoid
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Management of Fibroids in Pregnancy continued

performing a myomectomy at the should only be performed if unavoid- Uterine artery embolization. Bilat-
time of cesarean delivery due to the able to facilitate safe delivery of the eral uterine artery embolization (UAE)
well-substantiated risk of severe hem- fetus or closure of the hysterotomy. has long been performed by interven-
orrhage requiring blood transfusion, Pedunculated subserosal fibroids can tional radiologists to control postpar-
tum hemorrhage. More recently, UAE
Most authorities agree that every effort should be made to avoid performing has been used as an alternative proce-
dure for treating large symptomatic
a myomectomy at the time of cesarean delivery due to the well-substantiated
fibroids in women who are not preg-
risk of severe hemorrhage requiring blood transfusion, uterine artery liga- nant and, most importantly, do not
tion, and/or puerperal hysterectomy. desire future fertility.7 A recent
prospective study reported that UAE
uterine artery ligation, and/or puer- also be safely removed at the time of performed immediately after cesarean
peral hysterectomy.20,31,58,59 Myomec- cesarean delivery without increasing delivery in women with uterine fi-
tomy at the time of cesarean delivery the risk of hemorrhage.31 broids may be effective in decreasing

Table 2
Obstetric and Neonatal Outcomes in Normal Pregnant Women and Women
With/Without Antepartum Myomectomy

Pregnancies With Uterine Fibroids

With Without
Normal Pregnancies Myomectomy Myomectomy
(n  2463) (n  18) (n  88)
Age (y) 29 (26-40) 33 (28-40) 35 (29-40)
Nulliparous 1639 (66.5%) 16 (83.3%) 40 (45.4%)
Multiparous 824 (33.5%) 2 (16.7%) 48 (54.6%)
Gestational age at diagnosis (wk) – 11 (8-17) 13 (6-22)
Gestational age at myomectomy (wk) – 12 (10-19) –
Abortion 228 (9.3%) 0 12 (13.6%)
Premature membranes rupture 134 (5.4%) 1 (5.6%) 20 (22.7%)
IUGR 61 (2.5%) 1 (5.6%) 4 (4.5%)
Preterm labor 141 (5.7%) 1 (5.6%) 19 (21.6%)
Cesarean delivery (16.3%) (93.7%) (34%)
Postcesarean hysterectomy 3 (0.12%) 0 4 (4.5%)
Apgar score
7 2447 (99.3%) 18 (100%) 87 (98.9%)
7 16 (0.7%) 0 1 (1.1%)
Weight:
 2500 g 2283 (92.7%) 17 (94.4%) 80 (90.9%)
 2500 g 180 (7.3%) 1 (5.6%) 8 (9.1%)
Fibroids
Small ( 5 cm) 0 45
Medium (5-10 cm) 9 42
Large ( 10 cm) 9 1
IUGR, intrauterine growth restriction.
Reprinted with permission from Mollica G et al.53

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Management of Fibroids in Pregnancy

+
+ +
+
Fibroid

D1 3.51 cm
D2 3.88 cm
D1/D2 90%

B C

Fibroid
Placenta
+ + +
Fibroid Placenta
X
X
Lower uterine
segment
+

+ Dist 5.50 cm + Dist 7.82 cm

X Dist 6.97 cm

Figure 1. Representative images of fibroids in pregnancy. (A) A 3.5  3.8 cm fibroid is evident in the posterior uterine wall. This small
fibroid is unlikely to cause any pregnancy-related complications. (B) A 5.5  6.9 cm retroplacental fibroid is shown. This large fibroid is
likely to interfere with placentation and uteroplacental blood flow due both to its size and location, which may present clinically as
intrauterine growth restriction, placental abruption, or preeclampsia. (C) A 7.8 cm fibroid is evident in the lower uterine segment. Given its
size and location, this large fibroid may interfere with engagement of the fetal head near term and the normal progress of labor. Moreover,
the internal echogenic changes are consistent with “red degeneration,” and would likely account for the patient’s lower abdominal pain.

postpartum blood loss and minimiz-
ing the risk of myomectomy or hys-
terectomy by inducing shrinkage of
the fibroids.60 Although not recom-
mended, there are several reports of
successful and uneventful pregnan-
cies after UAE for uterine fibroids.60-63
Conclusions
Uterine fibroids are a very common
finding in women of reproductive
age. The majority of fibroids do not
change their size during pregnancy,
but one-third may grow in the first
trimester. Although the data are con-
flicting and most women with fi-
broids have uneventful pregnancies,
the weight of evidence in the litera-
ture suggests that uterine fibroids are
associated with an increased rate of
spontaneous miscarriage, preterm
labor, placenta abruption, malpresen-
tation, labor dystocia, cesarean deliv-
ery, and postpartum hemorrhage. Pain
is the most common complication of
fibroids during pregnancy. The symp-
toms can usually be controlled by
conservative treatment, but may re-
quire definitive surgical resection in
rare instances. Some women with a
previous myomectomy may need to
be delivered by elective cesarean
delivery prior to the onset of labor,
particularly if the uterine cavity was
entered. Women with a previous my-
omectomy should probably be deliv-
ered by cesarean prior to the onset of
labor, particularly if the uterine cavity
was entered. UAE is an alternative
procedure to operative intervention
for the treatment of symptomatic fi-
broids, but is absolutely contraindi-
cated in pregnancy and in women
desiring future fertility.
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Main Points
• Uterine fibroids are very common in women of reproductive age. Most are asymptomatic; however, severe localized abdominal
pain can occur if a fibroid undergoes so-called “red degeneration,” torsion, or impaction. Pain is the most common complication
of fibroids in pregnancy, and is seen most often in women with fibroids  5 cm during the second and third trimesters of preg-
nancy.
• Approximately 10% to 30% of women with fibroids develop complications during pregnancy, although these adverse pregnancy
outcomes have been reported in incomplete settings with selection bias, small and differing populations, varying inclusion crite-
ria, low occurrence of adverse outcomes, and inadequate confounding variables.
• In early pregnancy, spontaneous miscarriage rates are greatly increased in pregnant women with fibroids compared with those
without fibroids (14% vs 7.6%, respectively), and bleeding is significantly more common if the placenta implants close to the
fibroid. In late pregnancy, such complications include preterm labor, placental abruption, placenta previa, and fetal anomalies.
• Pain is the most common complication of fibroids during pregnancy. The symptoms can usually be controlled by conservative
treatment (bed rest, hydration, and analgesics), but may require definitive surgical resection in rare instances.
• Prior to pregnancy, myomectomy can be considered in women with unexplained infertility or recurrent pregnancy loss, although
whether this intervention improves fertility rates and perinatal outcome remains unclear. Uterine artery embolization is an alter-
native procedure to operative intervention, but is contraindicated in pregnancy and in women desiring future fertility.

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